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Physical Abuse Physical abuse, which is 19% of all substantiated cases of child abuse, is the most visible form of abuse and may be defined as any act which results in a non- accidental trauma or physical injury. Inflicted physical injury most often represents unreasonable, severe corporal punishment or unjustifiable punishment.

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Behavioral Indicators self destructive withdrawn and/or aggressive - behavioral extremes arrives at school early or stays late as if afraid to be at home chronic runaway (adolescent) complains of soreness or moves uncomfortably wears clothing inappropriate to weather, to cover body bizarre explanation of injuries

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What is neglect? Neglect includes:  Failure to provide a child with food, clothing, shelter, medical care.  Leaving a child in a situation where the child is at risk of harm.

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Child Neglect Neglect is a pattern of failing to provide for a child's basic needs, to the extent that the child’s physical and/or psychological well- being are damaged or endangered. In child neglect, the parents or caregivers are simply choosing not to do their job.

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There are three basic types of neglect. Physical Educational Emotional

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Physical Failure to provide adequate food, clothing, or hygiene. Reckless disregard for the child’s safety, such as inattention to hazards in the home, drunk driving with kids in the car, leaving a baby unattended. Refusal to provide or delay in providing necessary health care for the child. Abandoning children without providing for their care or expelling children from the home without arranging for their care.

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Educational Failure to enroll a child in school Permitting or causing a child to miss too many days of school Refusal to follow up on obtaining services for a child’s special educational needs

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Emotional Inadequate nurturing or affection Exposure of the child to spousal abuse Permitting a child to drink alcohol or use recreational drugs Failure to intervene when the child demonstrates antisocial behavior Refusal of or delay in providing necessary psychological care

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Signs of Neglect Clothes that are dirty, ill-fitting, ragged, and/or not suitable for the weather Unwashed appearance; offensive body odor Indicators of hunger: asking for or stealing food, going through trash for food, eating too fast or too much when food is provided for a group Apparent lack of supervision: wandering alone, home alone, left in a car Colds, fevers, or rashes left untreated; infected cuts; chronic tiredness In schoolchildren, frequent absence or lateness; troublesome, disruptive behavior or its opposite, withdrawal In babies, failure to thrive; failure to relate to other people or to surroundings

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Sexual Abuse Behavior involving penetration – vaginal or anal intercourse and oral sex Fondling – Touching or kissing a child's genitals, making a child fondle an adult's genitals. Violations of privacy – Forcing a child to undress, spying on a child in the bathroom or bedroom. Exposing children to adult sexuality – Performing sexual acts in front of a child, exposing genitals, telling "dirty" stories, showing pornography to a child. Exploitation – Selling a child’s services as a prostitute or a performer in pornography.

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Signs of Sexual Abuse Inappropriate interest in or knowledge of sexual acts Seductive behavior Reluctance or refusal to undress in front of others Extra aggression or, at the other end of the spectrum, extra compliance Fear of a particular person or family member

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Verbal Abuse Belittling or shaming the child: name-calling, making negative comparisons to others, telling the child he or she is “no good," "worthless," "a mistake." Habitual blaming: telling the child that everything is his or her fault.

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Withholding Affection Ignoring or disregarding the child Lack of affection and warmth: Failure to hug, praise, express love for the child

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Extreme Punishment These are actions that are meant to isolate and terrorize a child, such as tying the child to a fixture or piece of furniture or locking a child in a closet or dark room.

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Corruption This involves causing a child to witness or participate in inappropriate behavior, such as criminal activities, drug or alcohol abuse, or acts of violence.

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Causes of Child Abuse Stress, including the stress of caring for children, or the stress of caring for a child with a disability, special needs, or difficult behaviors Lack of nurturing qualities necessary for child care Immaturity: a disproportionate number of parents who abuse their children are teenagers Difficulty controlling anger Personal history of being abused Isolation from the family or community Physical or mental health problems, such as depression and anxiety Alcohol or drug abuse Personal problems such as marital conflict, unemployment, or financial difficulties.

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Reporting Child Abuse California Website: tm tm

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BRN – Registered Nurse Under California law each person licensed by the Board of Registered Nursing is a “Mandated Reporter” for child abuse or neglect purposes. Prior to commencing his or her employment, and as a prerequisite to that employment, all mandated reporters must sign a statement on a form provided to him or her by his or her employer to the effect that he or she has knowledge of the provisions of Section and will comply with those provisions.

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Physical Abuse

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Soft Tissue Injuries Bruises on face, lips, mouth, torso, back, buttocks, thighs  Especially in various stages of healing  Degree of bruising is greater than expected for the activity level of the child.

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Bruises

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Abnormal Bruising Patterns

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Abdominal Trauma

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Massive Bruising

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Broken Teeth

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Mouth Trauma

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Scald Burns

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Eye Trauma

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Retinal Hemorrhage

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A four-month-old Caucasian male who presented to the ER with a history of respiratory problems. Physical examination revealed multiple bruises, bilateral and frontal subdural hematomas by CT, and diffuse retinal hemorrhages and retinal folds on ophthalmic exam. Subsequently, the dad was charged with abuse. One month later after a prolonged stay in ICU he developed a seizure disorder and severe developmental delay. His retinal hemorrhages have not yet completely resolved.

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Chest X-ray Findings Posterior rib fracture of the 7 th rib. This fracture is less than 14 days old as there is no visible callus. Rib fracture is unrelated to child’s presenting complaint. Conclusion: Rib fractures a common injuries in the young (less than 2 years). Typically, is part of violent shaking. Child is held very tightly around the chest and squeezed while shaking.

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Case Study #4 3 ½ year old presents with 4 day history of persistent vomiting after eating and abdominal pain.

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Upper GI Series

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Upper GI Findings Duodenal hematoma (blood collection) in the wall of the bowel. Conclusion: This injury is almost always caused by direct trauma (assault, bicycle handlebar injury). Common injury in abuse and is typically seen in older children who are punched or kicked in the abdomen.

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Questions Is it developmentally possible for a six-week old to fracture a femur? Upon questioning the parents they report an incident when the infant was bumped against a door while carrying him in a padded infant carrier. The parents tell you it could not have been hard enough to cause a fracture.

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What is the diagnosis? Osteogenesis imperfecta. Occult types tend to be autosomal dominant Family history positive for fractures

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Does the injury match the history? In four of the case studies the presenting history did not match the physical / x-ray findings. In case study #5 a good family history provided a history of hereditary condition that can cause fractures.

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When are you required to submit an abuse report? “A mandated reporter shall make a report…whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child who the mandated reported knows or reasonably suspects has been the victim of child abuse or neglect.” Cal. Penal Code 11166(a).

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What if I am not sure that abuse has occurred? Confirmation of abuse is not required. Reporters must report whenever they have “reasonable suspicion” that abuse has occurred.

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Reasonable Suspicion “Reasonable suspicion” means “that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and expertise, to suspect child abuse or neglect.” Cal. Penal Code 11166(a)

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Board of Registered Nursing A BSN prepared nurse may apply for public health certification based on the fact the he / she has had content related to:  Domestic Abuse  Child Abuse  Geriatric Abuse